Browse the corpus

With the improvement in social equity and women’s education and job prospects over recent decades, China has witnessed the postponement of marriage and childbearing.7 From 1990 to 2020, the average age at which women married for the first time increased nationwide from 22 to 28 years. The mean age at first birth also rose.7 Given the delay in marriage and childbearing and more open attitudes towards sex, the prevention of unintended pregnancy and sexually transmitted infections (STIs) is becoming important among young women and men. In addition, the growing sexual activity among adolescents in China also warrants urgent recognition and action to avoid the adverse physical and psychological impacts of STIs, unintended pregnancy, and repeated abortion.5 Finally, as most women of reproductive age in China are employed, birth spacing is essential for married couples.

growing sexual activity among adolescents in China also warrants urgent recognition and action to avoid the adverse physical and psychological impacts of STIs, unintended pregnancy, and repeated abortion.5 Finally, as most women of reproductive age in China are employed, birth spacing is essential for married couples. These changes indicate that preventing unintended pregnancies, subsequent abortions, and STIs should be priorities for contemporary contraceptive services. Evidence shows that full provision of contraceptive services can result in a 52% decline in both unintended pregnancies and abortions.6 Scaling up barrier contraception and advocating dual protection can prevent more STIs.5 8 Secondary contraceptive benefits also include physical and psychological health, girls’ education, women’s rights and career development, and gender equality. In essence, the old mission of curbing the population growth among married couples needs to be replaced by a new mission of improving the health, prospects, and family wellbeing of all people of reproductive age.

China’s family planning services evolved from being scarcely available in the 1950s and 1960s to becoming a nationwide priority from the 1980s to the mid-2010s with the introduction of the one child policy.5 However, after the policy was relaxed, the family planning system was merged into the maternal and child health programme, a national hierarchical network responsible for providing medical care, health maintenance, and health administration for reproductive, women’s and children’s health from national to village levels.5 Although contraceptive services are now provided as part of the essential public health service programme, the staff working for the national family planning programme were not transferred. Additionally, the new service focuses on providing free contraceptives and surgical methods to married couples.9 A new infrastructure is therefore needed to efficiently meet the family planning needs of all people of reproductive age and make up for the shortfall in the workforce. The services required for delivering contraceptives vary depending on the method, ranging from self-service (eg, condoms) or pharmacy services (eg, contraceptive pills) to well trained medical services (eg, IUDs). Here, we propose a three level system model of provision, including self-care, community clinics, and hospitals. Corresponding facilities, products, and services are tailored to each level (box 1).

rom self-service (eg, condoms) or pharmacy services (eg, contraceptive pills) to well trained medical services (eg, IUDs). Here, we propose a three level system model of provision, including self-care, community clinics, and hospitals. Corresponding facilities, products, and services are tailored to each level (box 1). This mainly involves short acting methods, such as male and female condoms, hormonal pills, and emergency contraceptive pills. Postpartum women can use the lactational amenorrhoea method. Self-administration of injectable contraception should be encouraged.10 Self-care can efficiently promote health and ease the strain on the existing health system.11 An efficient level 1 service requires a high quality school and public education system, widescale condom distribution, easy access to pharmacies, and an efficient pharmacy delivery system. Good linkage of self-care to the relevant community or facility based healthcare services is also important.

ting health system.11 An efficient level 1 service requires a high quality school and public education system, widescale condom distribution, easy access to pharmacies, and an efficient pharmacy delivery system. Good linkage of self-care to the relevant community or facility based healthcare services is also important. Community health workers provide public education and contraceptive advice to help both adolescents and adults make informed decisions and ensure their access to contraception products. Advice should be based on up-to-date and evidence based information, including the benefits, options, effectiveness, side effects, and costs. Injectable contraceptives can be provided, as well as implants and IUDs when adequate resources and trained staff are available. High quality level 2 services require a framework for rigorous training, up-to-date training materials, and adequately trained health workers. Community clinics also have a key role in postpartum contraception. In China, maternity hospitals and obstetrics and gynaecology departments in general hospitals are the main providers of long term contraceptive methods such as implants, IUDs, and female and male sterilisation. Hospital health professionals can also provide contraceptive education for girls and women, especially in post-abortion care. A close partnership between the community and hospitals is important to establish a comprehensive and continuous service. Maternity hospitals are also responsible for providing technical support and training for community health workers

vide contraceptive education for girls and women, especially in post-abortion care. A close partnership between the community and hospitals is important to establish a comprehensive and continuous service. Maternity hospitals are also responsible for providing technical support and training for community health workers For each level in the new infrastructure of contraceptive services, the available resources and staffing are crucial. Providing space, supplies, and equipment, as well as technology, information, and knowledge, requires sufficient financial support. In China, it was estimated that it would cost $7 (£5.50; €6.50) per capita annually (compared with current $5.47) if all needs are met, and every additional dollar spent on contraceptive services would save $2.50 in the cost of pregnancy related care for unintended pregnancies.6 Therefore, additional investment is necessary if the new, broader mission of improving the health and wellbeing of everyone of reproductive age is to be achieved.

This mainly involves short acting methods, such as male and female condoms, hormonal pills, and emergency contraceptive pills. Postpartum women can use the lactational amenorrhoea method. Self-administration of injectable contraception should be encouraged.10 Self-care can efficiently promote health and ease the strain on the existing health system.11 An efficient level 1 service requires a high quality school and public education system, widescale condom distribution, easy access to pharmacies, and an efficient pharmacy delivery system. Good linkage of self-care to the relevant community or facility based healthcare services is also important.

Community health workers provide public education and contraceptive advice to help both adolescents and adults make informed decisions and ensure their access to contraception products. Advice should be based on up-to-date and evidence based information, including the benefits, options, effectiveness, side effects, and costs. Injectable contraceptives can be provided, as well as implants and IUDs when adequate resources and trained staff are available. High quality level 2 services require a framework for rigorous training, up-to-date training materials, and adequately trained health workers. Community clinics also have a key role in postpartum contraception.

In China, maternity hospitals and obstetrics and gynaecology departments in general hospitals are the main providers of long term contraceptive methods such as implants, IUDs, and female and male sterilisation. Hospital health professionals can also provide contraceptive education for girls and women, especially in post-abortion care. A close partnership between the community and hospitals is important to establish a comprehensive and continuous service. Maternity hospitals are also responsible for providing technical support and training for community health workers

At the self-care level, the dissemination of contraceptive knowledge in the school and public education system is essential to our new mission. In 2021, the Chinese State Council adopted outlines for women’s development and children’s development for 2021-30. The plans underlined the importance of the dissemination of sexual knowledge to women and children and the role of school education.12 13 Comprehensive sex education needs to be incorporated into the school curriculum to educate young people about contraception and the choices available at various levels. In the Netherlands, for example, sex education has been mandatory in primary and secondary schools since 2012, and this has contributed to the high prevalence of contraceptive use, low rates of adolescent pregnancy, birth, and abortion, low STI rates, and low unmet needs.14

and the choices available at various levels. In the Netherlands, for example, sex education has been mandatory in primary and secondary schools since 2012, and this has contributed to the high prevalence of contraceptive use, low rates of adolescent pregnancy, birth, and abortion, low STI rates, and low unmet needs.14 Public education is also required to facilitate the dissemination of contraceptive knowledge and reduce the barriers of social prejudice and misinformation. Recent national reports suggest that China has about 1.1 billion mobile internet users, and about 90% of adolescents use smartphones.15 16 Additionally, the number of people accessing short videos and live streaming is 1 billion and 0.8 billion, respectively.15 Therefore, new approaches such as social media campaigns, video sharing platforms, and live streaming may also help promote the availability and appropriate use of contraception. In addition, sex education can be more effective when complemented by community based services, such as community education, contraception counselling, and condom distribution.

The realisation of women’s sexual and reproductive health and rights is a cornerstone of the new mission.17 Access to a choice of affordable and acceptable methods of contraception for all women of reproductive age is vital.17 A study showed that free distribution of condoms increased their use from 28% to 36% by women and from 40% to 54% by men.18 Although the Chinese government continues to provide free contraceptives, public awareness of the policy, the types of contraception available, and how to acquire them needs to be raised, especially among people with low income or low educational levels and new migrants.19 20 21 Public awareness of free long-acting contraceptives is lower than that of free condoms.19 21 Since the original government initiative targeted married couples of reproductive age, more efforts are needed to increase the awareness of free contraceptives for unmarried people through the public and school education system.19 21 Lower satisfaction with the quality and comfort of free condoms has also been reported.21 22 Further investment and publicity are therefore needed to promote public awareness and ensure the quality of products.

he awareness of free contraceptives for unmarried people through the public and school education system.19 21 Lower satisfaction with the quality and comfort of free condoms has also been reported.21 22 Further investment and publicity are therefore needed to promote public awareness and ensure the quality of products. Convenient access is another factor in the distribution of free contraceptives.20 Online pharmacies and online healthcare services are well suited for the supply of condoms and pills. In 2023, more than 0.5 billion and 0.3 billion people in China were estimated to have used online ordering and online healthcare services, respectively.15 China also has an efficient delivery system that can bring both over-the-counter and prescription drugs to people quickly in urban settings. Nevertheless, some studies found that women in urban areas had a higher incidence of unintended pregnancy and abortions than rural women, probably because of a more open attitude towards sex and a lower proportion of women using highly effective contraceptive methods in urban areas.23 24 In addition, migrants showed poor awareness and insufficient use of family planning services.25 Thus, investment to increase awareness and motivate women to use more effective methods is needed for urban residents and migrants. In contrast, in remote and rural areas with low internet penetration and weak delivery capacity, investment in easy access to contraception—for example, through community clinics and convenience stores—is essential for services and products to reach as many people as possible.

Training, certification, and ongoing performance evaluation of family planning providers in the community and hospital services are needed to optimise the role. This should include attitudes and professional and practice competencies.26 Currently, family planning providers in community clinics are often unable to provide individualised contraceptive counselling and meet the complex needs of clients because they lack systematic medical training and clinical experience.21 Thus, adequate training is urgently needed for community health workers, especially in remote and rural settings where they have a central role in counselling and delivering family planning.

eptive counselling and meet the complex needs of clients because they lack systematic medical training and clinical experience.21 Thus, adequate training is urgently needed for community health workers, especially in remote and rural settings where they have a central role in counselling and delivering family planning. Post-abortion and postpartum contraceptive services are the two weakest areas currently. At least 70% of the pregnancies among women in the first postpartum year were reported to be unintended.27 A retrospective cohort study among 17 466 postpartum women at 60 hospitals in 15 provinces in China showed that the rates of unmet needs for postpartum modern family planning methods between 2015 and 2016 were 35.5%, 25.6%, and 24.6% at 6, 12, and 24 months postpartum, respectively.28 For post-abortion contraceptive counselling, a nationwide cross-sectional study among 561 service providers in 30 provinces in 2013 found that their overall knowledge of contraception was limited, and only 57% spent more than 10 minutes on counselling.29 Another cross-sectional survey among 431 women in three public hospitals in Guangzhou in 2018 reported that 42% of the women undergoing abortion used post-abortion services, including contraceptive counselling and provision. The proportion of migrants using the post-abortion services was significantly lower than that of residents (19% v 80%).30

rvey among 431 women in three public hospitals in Guangzhou in 2018 reported that 42% of the women undergoing abortion used post-abortion services, including contraceptive counselling and provision. The proportion of migrants using the post-abortion services was significantly lower than that of residents (19% v 80%).30 The reasons for the unmet needs include a lack of trained health workers and space, heavy workloads among providers, and disconnection between the maternal healthcare system and the contraceptive service system.27 28 29 Providing postpartum contraceptive service at the same time as “well baby” visits may be feasible and acceptable to both women and providers, according to a recent study in Shanghai.31 The integration of post-abortion and postpartum care into community clinics and hospitals warrants more support and investment.

The current contraception options do not fully meet women’s needs and align with their preferences, and the development of new technologies has remained stagnant for decades.32 The failure rates (the proportion of women who will become pregnant within the first year after initiating method use) of short acting methods remain high. Longer acting methods such as implants and IUDs require medical visits and invasive procedures, and side effects stop many women from using hormonal products.32 Affordable and desirable methods with more convenience, higher reliability, and fewer side effects need to be developed. Additional investment should also be made to address data gaps by monitoring the family planning progress and establishing a nationwide contraception database covering urban and rural areas, migrants, adolescents, and married and unmarried adults. The patterns of contraceptive use, efficacy, safety, and management of side effects should be included in the database.

The new, wider mission for contraceptive services and optimisation strategies cannot be achieved without policy, funding, and publicity support, and coordination by government and non-governmental organisations (NGOs). Furthermore, to tailor contraceptive services to the needs and preferences of different age and marital groups, government and NGOs need to achieve a wider mix of methods through the three level system. IUDs, female sterilisation, and condoms have been the dominant methods of contraception in China for many decades.33 However, the proportion using condoms increased rapidly after the relaxation of fertility policies, and the uptake of other methods, such as contraceptive pills, injectables, and implants, remains low.33 34 Although contraception is provided free in China’s essential public health service programme, lack of awareness and familiarity among both consumers and providers, the concerns about side effects, and misconceptions about safety and effectiveness remain considerable barriers to greater use.19 34 35 36

remains low.33 34 Although contraception is provided free in China’s essential public health service programme, lack of awareness and familiarity among both consumers and providers, the concerns about side effects, and misconceptions about safety and effectiveness remain considerable barriers to greater use.19 34 35 36 Achieving a balanced method mix requires the support of the government and NGOs. The national Management Centre for Drugs and Medical Devices (responsible for the supply, management, and guidance of free contraceptives and services among others functions) and its counterparts at the provincial level, should optimise the regulations, strengthen the supply chain systems, and address research gaps to expand the coverage of free contraceptives. The China Family Planning Association, which is the country’s largest NGO in reproductive health and a member of the International Planned Parenthood Federation, could have an important role in the three level system, including in school and public education and staff training. In addition to making existing free contraceptives more available, expanding the range of options is also critical. More effort is needed to address the affordability and improve the awareness and access to new methods, such as the new generation oral contraceptive.

With the relaxation of the fertility policy and a changing social environment in China, more attention needs to be paid to meeting the contemporary demands for contraception and optimising contraceptive services. As well as shifting the focus from birth control to ensuring the health and wellbeing of girls and women, contraceptive services should also be expanded to include adolescents and men. Fulfilling the need for modern contraception would not only help build a healthy, friendly, and supportive environment for everyone in need of contraception in China but also meet the global commitment to leave no one behind. The mission of the family planning service needs to move from birth control to ensuring the health and wellbeing of all people of reproductive age Changes are needed to improve access, equity, and quality of services Infrastructure and investment should be centred around a three level contraceptive service encompassing individuals, communities, and hospitals